PNHP

Stephanie Woolhandler, MD: Bankruptcy due to medical bills remains a problem

Stephanie Woolhandler, MD: Bankruptcy due to medical bills remains a problem

By MedPage Today Staff
MedPage Today, April 18, 2017

Bankruptcy is common in the U.S., and medical bills often play a role — even for people with health insurance, according to Stephanie Woolhandler, MD, of the Albert Einstein College of Medicine, in New York City. The number of bankruptcies ranges from 1 million to about 1.5 million per year depending on how well the economy is doing, and medical bills are by far the most common item sent to collection agencies, she noted.

Following is a transcript of her remarks:

Three-quarters of people who are bankrupted by medical costs actually had insurance, at least when they first got sick. Many of them lost their insurance because they lost their job when they got sick, but for the majority of them, they managed to hold on to private insurance throughout the bankrupting illness, but were bankrupted anyway by gaps in their coverage like co-payments, deductibles, and uncovered services.

In our studies, we found that well over half of all bankruptcies were due, at least in part, to medical illness or medical bills. In 2007, for instance, about 62% of all personal bankruptcies were related to medical causes. Bankruptcy is extremely common in this country. When the economy is doing well, there’s about a million bankruptcies a year. When it does poorly, the numbers rise closer to one and a half million.

So in the United States for a woman, bankruptcy is about as common as graduating from college, so it’s a very, very common experience and well over half of the time it’s due to medical illness or medical bills, at least in part.

The new administration and Congress [are] taking a lot of steps that are going to raise co-payments and raise deductibles and make health insurance even skimpier than it is today. So we would certainly expect to see many more people driven into bankruptcy by healthcare costs, including many people with insurance, only their insurance is so partial that it doesn’t protect them when they have a serious or prolonged illness.

We finished up our studies in 2009, but the Consumer Financial Protection Bureau has been following the problem of people getting medical debts referred to collection agencies, and it turns out that medical bills are by far the most common item that are sent to collection agencies and end up on credit reports because of unpaid bills. Medical bills are about six to eight times more common than other items like cellphone bills, cable TV, utilities, retail.

So well over half of all the black marks that people have on their credit reports that worsen your credit are due to medical bills. So that has a lot of consequences because if your credit score goes down, that can make it more expensive to purchase insurance, difficult or impossible to buy a home or rent a home, maybe even affect your ability to get a much needed job if your potential employer checks your credit scores and sees that it’s low. So medical bills are having a very serious impact on family finances and family credit all the time, and in many cases, they do result in a personal bankruptcy.

full video:
http://www.medpagetoday.com

Inappropriate medical debt collection

Medical Debt Malpractice

United States Public Interest Research Group (U.S. PIRG), April 11, 2017

Millions of Americans are contacted by debt collectors every year over debt related to medical expenses.

Medical debt collectors often employ aggressive tactics and attempt to collect debt from the wrong customers – putting consumers’ credit records at risk. Medical debt accounts for more than half of all collection items that appear on consumer credit reports. A review of 17,701 medical debt collection complaints submitted to the Consumer Financial Protection Bureau (CFPB) shows that problems with medical debt collection are widespread and harm Americans across the country.

Complaints submitted to the CFPB suggest that many consumers contacted about medical debt should not have been contacted in the first place, and that many contacts involve aggressive or inappropriate tactics.

* Nearly two-thirds (63%) of complaints about medical debt collection assert either that the debt was never owed in the first place, it was already paid or discharged in bankruptcy, or it was not verified as the consumer’s debt.

* Many complaints document inappropriate and aggressive tactics including frequent or repeated calls, calls harassing friends and family, threats of legal action, or the use of abusive language.

Medical debt collection affects a broad swath of the population and subjects millions of consumers to undue stress and financial harm. State and federal policymakers should work to protect consumers from unfair treatment by medical debt collectors.

Federal policymakers should also defend the CFPB against attempts to eliminate or cripple it, and should continue to ensure the CFPB has the resources, independence and tools at its disposal to effectively protect consumers from all kinds of predatory financial behavior.

http://www.uspirgedfund.org…

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Medical Debt: You May Not Owe It

By Ann Carrns
The New York Times, April 12, 2017

Nearly two-thirds of people who complained to federal regulators about medical debt collectors said they did not owe the money, a new report found.

The report, by the advocacy group United States Public Interest Research Group — better known as U.S. PIRG — and the Frontier Group, a left-leaning think tank, examined more than 17,000 publicly available complaints about medical debt collection filed with the Consumer Financial Protection Bureau over more than three years.

Chi Chi Wu, a lawyer with the National Consumer Law Center, said the findings in part reflected the complexity of the health care payments system, which often involves insurers that may pay all or part of the cost of care. Consumers may not understand the details of how their health insurance works, and may think that it covers more than it actually does. Co-payments and deductibles — the amount that you pay before insurance does — can often trip people up.

“The medical and health care billing process is just really confusing and complicated,” Ms. Wu said.

https://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

The United States is unique in having a massive amount of personal medical debt when we are spending twice the amount per person on health care than the average of other wealthy nations in which medical debt is much less common. What is wrong here?

The primary defect is in the way we finance health care – especially depending on private sector intermediaries (the insurance industry) that create innovative methods of financing health care that work very well for their own industry but work poorly for patients with health care needs. This flawed system has created greater opportunities for the debt collection industry which, again, serves its own industry well but also works very poorly for patients.

Regular readers know that a well designed single payer system would eliminate much of this waste and grief. What is difficult to understand is why we have failed to enact an improved Medicare for all program before now. It is long past due.

Elisabeth Rosenthal: ‘An American Sickness’

How Healthcare Became Big Business and How You Can Take It Back

By Elisabeth Rosenthal
Penguin Random House, April 2017

From the Introduction

Everyone knows the healthcare system is in disarray. We’ve grown numb to huge bills. We regard high prices as an inescapable American burden.

The current market for healthcare just doesn’t deliver. It is deeply, perhaps fatally, flawed. Even market economists themselves don’t believe in it anymore.

All the harrowing tales in this book occurred despite the 2010 passage and the 2014 enactment of the Patient Protection and Affordable Care Act (the ACA, also known as “Obamacare”). The ACA is not a failure, as some still assert, but the “affordable” in its name was an overreach to win over votes and public opinion.

Each market has certain rules that are determined by the conditions, incentives, and regulations under which it operates. Currently, we buy and sell medical encounters and accoutrements like commodities, but how do participants in the marketplace make purchasing choices? Prices are often unknowing and unpredictable; there’s little robust competition for our business; we have scant information on quality to guide our decisions; and very often we lack the power ourselves to even choose.

The rules governing the delivery of health care in the United States have grown out of the market’s design. The type of healthcare we get these days is exactly what the market’s financial incentives demand. Some have to get wise to them, and be smarter, far more active participants in this ugly, rough-and-tumble world. More important, we have to change the rules of the game, with different incentives and new types of regulation.

The economist Adam Smith spoke of an “invisible hand” with respect to income distribution. But in American healthcare, there’s a different type of invisible hand at work: it’s on the till.

http://www.penguinrandomhouse.com…

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Why an Open Market Won’t Repair American Health Care; A Review of Elisabeth Rosenthal’s “An American Sickness”

By Jacob S. Hacker
The New York Times, April 4, 2017

It was March 2012, and the Affordable Care Act (a.k.a. Obamacare) was before the Supreme Court. Justice Antonin Scalia zeroed in on its controversial requirement that all Americans purchase health insurance. Yes, everybody needs health care, Scalia conceded, but everybody needs food too. If the government could make people buy insurance, why couldn’t it “make people buy broccoli”?

The Affordable Care Act survived, of course — though not before a fractured court made the expansion of Medicaid optional, leaving millions of poorer Americans without its promised benefits. But the question Justice Scalia asked remains at the heart of a debate that has only intensified since: Why is health care different? Why does it create so much more anxiety and expense, heartache and hardship, than does buying broccoli — or cars or computers or the countless other things Americans routinely purchase each day?

For those leading the charge to roll back the 2010 law, the question has a one-word answer: government.

Where Rosenthal’s account falls short is in explaining why this deeply broken system persists. Early on, Rosenthal seems to side with Speaker Ryan and Senator Paul, describing “the very idea of health insurance” as “in some ways the original sin that catalyzed the evolution of today’s medical-industrial complex.” But, as Rosenthal (too briefly) discusses, countries where people are much better insured don’t have anything like our self-dealing, upside-down incentives and outrageous costs. Somehow, despite largely keeping citizens’ skin out of the game, other rich democracies manage to have much lower costs per person — as well as greater utilization of physician and hospital services and better basic health measures.

The difference between the United States and other countries isn’t the role of insurance; it’s the role of government. More specifically, it’s the way in which those who benefit from America’s dysfunctional market have mobilized to use government to protect their earnings and profits. In every country where people have access to sophisticated medical care, they must rely heavily on the clinical expertise of providers and the financial protections of insurance, which, in turn, creates the opportunity for runaway costs. But in every other rich country, the government not only provides coverage to all citizens; it also provides strong counterpressure to those who seek to use their inherent market power to raise prices or deliver lucrative but unnecessary services — typically in the form of hard limits on how much health care providers can charge.

In the United States, such counterpressure has been headed off again and again. The industry and its elected allies have happily supported giveaways to the medical sector. But anything more, they insist, will kill the market. Although this claim is in conflict with the evidence, it is consistent with the goal of maximum rewards to (and donations from) the industry.

Without a clear view of the political economy of health care, it’s easy to see the problem as Justice Scalia did. If we could just start treating health care like broccoli, the market would solve the problem. But as Rosenthal’s important book makes clear, the health care market really is different. Speaking of her Times series in 2014, Rosenthal told an interviewer her goal was to “start a very loud conversation” that will be “difficult politically to ignore.” We need such a conversation — not just about how the market fails, but about how we can change the political realities that stand in the way of fixing it.

https://mobile.nytimes.com…

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Comment:

By Don McCanne, M.D.

In her book, “An American Sickness,” Elisabeth Rosenthal has provided an excellent description of the dysfunction of the business model of health care delivery in the marketplace. On this basis alone it is an invaluable resource for every health policy library – home or institutional.

Rosenthal makes a valiant effort to describe what we can do about it, but she does so apparently under the assumption that we are going to have to live with this system for the indefinite future. Her recommendations largely require a very aggressive stance in dealing with the health care delivery system, especially with the business transactions. A limitation of this approach is that it requires not only access to the system by virtue of good insurance coverage or personal wealth, but it also requires a personality capable of rough-and-tumble negotiations. Most people would not really qualify and thus would not be effective in taking on the medical-industrial complex. She also quite appropriately recommends more aggressive regulation, though, except for the quite modest reforms of ACA, that has not been forthcoming in the environment of political polarization that has dominated the scene in the past few decades.

However this “sickness” is unique in the United States, so hope springs from observing how other nations have made their systems work. I am going to yield to Yale political science professor Jacob Hacker, who also reviewed her book, to provide us with a description of what accounts for other nations’ success, but in one word, it is government.

Rosenthal mentions single payer, but is far too timid here, suggesting, at most, allowing individuals over 55 to purchase Medicare. It is true that single payer reform alone would not correct all of the sins of capitalizing on unfettered market opportunities for excess revenues, but changing the milieu from the market business model to the public patient service model would go a long way toward realigning incentives of the providers. It would be a refreshing environmental change to concentrate on how the health care needs of the patients can best be served instead of wasting time trying to figure out how to pull in more big bucks.

Sorry, Republicans, but most people support single-payer health care

By Catherine Rampell
The Washington Post, April 17, 2017

Despite the rise of the tea party and unified Republican control of government, one decidedly anti-free-market idea appears ascendant: single-payer health care.

And it’s no wonder, given that a record-high share of the population receives government-provided health insurance. As a country, we’ve long since acquiesced to the idea that Uncle Sam should give insurance to the elderly, veterans, people with disabilities, poor adults, poor kids, pregnant women and the lower middle class.

Many Americans are asking: Why not the rest of us, too?

A recent survey from the Economist/YouGov found that a majority of Americans support “expanding Medicare to provide health insurance to every American.” Similarly, a poll from Morning Consult/Politico showed that a plurality of voters support “a single payer health care system, where all Americans would get their health insurance from one government plan.”

Divining the longer-term trend in attitudes toward this idea is difficult, as the way survey questions on the topic are asked has changed over time. Views of a health-care system in which all Americans get their insurance from the government single payer vary a lot depending on how you frame the question. Calling it “Medicare for all,” for example, generally elicits much stronger approval, while emphasizing the word “government” tends to depress support.

But at the very least, some survey questions that have remained consistent in recent years show support has been rising back up over the past few years for the broader idea that the federal government bears responsibility for making sure all Americans have health-care coverage.

In a way, stronger public support for single payer is the logical conclusion of recent health-insurance trends.

Since 1987, the share of Americans who receive some sort of public insurance has roughly doubled, to about 4 in 10  as of 2015. That’s not even counting the people who receive subsidies to buy private insurance on the Affordable Care Act exchanges.

The increase in the share of Americans on government insurance is partly due to demographics (baby boomers aging into Medicare) and partly due to deliberate policy changes growing the pool of Americans eligible for government insurance (such as the creation of the Children’s Health Insurance Program and Obamacare’s Medicaid expansion).

Expansions of government coverage have been cheered on by many liberals, but they have also bred suspicion and jealousy.

In both the recent YouGov and Morning Consult polls, for example, the age group most opposed to single payer was the only one that basically already has it: those 65 and up. In other words, single payer for me but not for thee.

That’s not because older Americans hate their experience with Medicare and wouldn’t wish something similar upon their worst enemy. To the contrary, those on Medicare are more satisfied with how the health-care system works for them than people on private insurance are, according to Gallup survey data.

Rather, seniors are probably worried that expanding government coverage to more Americans could put their own generous benefits at risk. That is, they want single-payer enthusiasts to keep your government hands off their Medicare.

Many of those not among the growing pool of public-insurance beneficiaries, on the other hand, have become resentful of the fact that everyone else seems to be getting a big fat government handout. Or so they perceive.

Many of the stories in the booming “blue-state reporter ventures into Trump country” genre have featured Trump supporters with deep hostility toward Obamacare, among other government programs. Some of these Trump supporters are, perhaps puzzlingly, themselves Obamacare beneficiaries, receiving government subsidies for private insurance on the individual exchanges. But often what these Trump voters say they want is not a return to pre-Obamacare days; rather, they want in on the great insurance deal that they think their lazy, less-deserving neighbors are getting.

In fact, that recent YouGov poll found that 40 percent of Trump voters support expanding Medicare to all Americans. Among Republicans overall, the share rises to 46 percent.

Among Republican politicians, needless to say, attitudes are somewhat different.

Expanding public health coverage to more people costs a lot of money, which doesn’t exactly jibe with their tax-cutting agenda. House Speaker Paul D. Ryan (R-Wis.) and his congressional compatriots seem to further believe — despite all evidence to the contrary — that the private sector is on the verge of some innovation that will magically reduce health-care costs and give all Americans the coverage and care they yearn for.

But it’s probably not fair to paint Republicans as the only roadblock here. Even Democrats don’t have the stomach for the battle required to replace our jury-rigged, mostly employer-sponsored insurance system with single payer. Which is understandable — while I also favor universal health-insurance coverage, I’m skeptical it will be achieved through single payer, given both the state of our political process and Americans’ cultural allergy to tax hikes.

Even so, somewhere out there, Bernie Sanders is smiling.

https://www.washingtonpost.com…

Docs want single-payer and so should you

By Phil Arvia
Daily Southtown, April 17, 2017

Obamacare, Trumpcare, I don’t care.

There is no fixing U.S. health care as it now teeters, a festering bureaucracy that spends more money on patients than any other country in the world yet lets them die faster than many nations supposedly our lesser siblings.

I can give you the facts of our failings: Health care spending in the U.S. as a percentage of GDP is 1.5 times that of any country you’ve heard of. In the 34-nation Organization for Economic Co-operation and Development, the average is 3.1 physicians and 3.4 hospital beds for every 1,000 people, while those figures in the U.S. are 2.4 and 2.6. In 2010, the average life span in OECD countries was 79.8 years; in the U.S., 78.7. Medical expenses, according to a Harvard University study of bankruptcy court statistics, account for roughly 62 percent of all personal bankruptcies in the U.S. — and 72 percent of that group had health insurance.

So go ahead, repeal and replace Obamacare — President Donald Trump was maneuvering in that direction again last week — with something else that keeps the public sick and insurers rich. Or do something that an allegedly great and Christian nation should demand: A single-payer system — Medicare for all — that ensures everyone has all the medical care they will ever need.

It’s the only thing that makes sense. Ask a doctor. Judging by the surveys, there’s a 60 percent chance that doc is a single-payer proponent.

“That is correct,” said Dr. Susan Rogers, an attending physician at Cook County Hospital and a board member of Physicians for a National Health Program. “Over the last 30 or 40 years, when managed care came along, the administration of health care became super complicated and labor-intensive. We’re spending more time on administration and documentation than actual health care.

“Physicians are very, very frustrated.”

Were the single-payer plan currently espoused by Bernie Sanders in place, frustration would fall away.

“People would be healthier,” Rogers said. “The workforce would be stronger, families would be stronger. When everyone is healthier, everything works better.

“Most older people are satisfied with traditional Medicare. And if you look at other countries with single-payer systems and how people feel about their care, it is not a source of stress.”

Stress is our current system’s chief product — for patients and providers alike.

“Right now, there’s an economic incentive for insurance companies not to pay doctors,” said Dr. Peter Orris, the chief of occupational and environmental medicine at University of Illinois Health. “That’s the origin of the huge administrative overhead that’s inflating costs in this country.”

Roughly 28 percent of health care spending in the U.S. is on administrative costs. Medicare shuffles its papers much more efficiently, as do virtually all other Western nations.

“Single-payer is the only system that addresses cost,” Rogers said. “Single-payer eliminates the market forces and administrative costs that drive the cost of health care up.”

It also eliminates the ridiculous premise that health care can be pursued in our capitalist, free-market society like a new car or a flat-screen. Because, sure, doc, you say I need an appendectomy, but let me shop around for a better deal on the anesthesiology, or at least for a hospital that will thrown in the sponge bath for free.

(By the way, according to the International Federation of Health Plans, in 2014 the average appendectomy in the U.S. ran about $16,000, and in Australia about $3,800.)

“Free markets are based on full knowledge on the part of the buyers and the sellers — and that’s impossible here,” Orris said. “The only thing single-payer takes out of the equation is private insurance agencies, which add nothing to the process except cost and complication.”

The 2013 Commonwealth Fund International Health Policy Survey suggested that if the U.S. had Canada’s health care system, 57 million fewer adults would go without health care because of cost; $1.3 trillion fewer dollars would be spent; 5,400 fewer infant deaths would occur; and 56,000 fewer preventable deaths would occur.

And the patients aren’t the only ones who’d fare better.

“Doctors would make more money because they’d have more time to see patients and that whole administrative issue would be resolved,” Rogers said. “Doctors could be doctors again.”

But what about research? Would the next wonder drug be stymied if the pharmaceutical companies couldn’t sell cancer drugs here at nine times the price they fetch in the United Kingdom?

“If you look at who is funding research, the government is already funding the bulk of it through grants,” Rogers said. “And statistics show single-payer countries are producing more journal articles that the U.S.”

Here in the greatest country on earth, our medical system seems simply to produce opioid addicts and opinion pieces.

We should demand more.

http://www.chicagotribune.com…

Single-payer not same as socialized medicine

By James Garb, M.D.
Cape Cod Times (Hyannis, Mass.), April 16, 2017

While I wholeheartedly support Carl Yingling’s desire for universal single-payer health care (“Americans need socialized medicine,” Letters, April 11), it’s important not to conflate that with “socialized medicine.”

The term socialized medicine is about care delivery, and means that all health care providers and hospitals work for the government, which would control how and where care is delivered; I’m not aware of anyone advocating that. The only “socialized” health care in America is the veterans health system. Anything beginning with the word “socialized” is a nonstarter for most Americans.

Alternatively, single-payer is about insurance, and means replacing our inefficient, costly patchwork system of competing private insurance with a nonprofit program (expanded Medicare) that would save more than $500 billion per year, enough to pay for privately provided universal health care, while eliminating copays and deductibles. It would help contain rising health care costs through streamlined administration, bulk purchasing and global budgeting.

Medicare has low administrative overhead and high approval ratings. Instead of covering only the oldest, sickest among us, expanded Medicare would be strengthened by bringing younger, healthier people into the pool, lowering the overall cost per member.

Mr. Yingling is correct that most industrialized countries have universal single-payer health care, and that should be our goal as well.

http://www.capecodtimes.com…

Single-Payer Health Care Is Seeing Record Support in Congress

By Michael Corcoran
Truthout, April 16, 2017

The primary Medicare for All bill has more support in Congress now than it has ever before.

John Conyers’ Medicare for All bill (HR 676), which he has introduced in each Congress since 2003, has seen a recent surge of new cosponsors — 32 since March 8 and nine on April 3 alone. As of this writing there are 93 co-signers (and counting), representing more than 48 percent of the Democratic Caucus. This is the highest number of cosponsors ever, both in terms of members and as a percentage of the House Democratic Caucus. The count is up from just 62 cosigners — 33 percent of Democrats — in the last Congress, and an average of 37 percent since the bill was first introduced in 2003.

This is an astonishing development for many reasons. Just a year ago the Democratic establishment was recklessly (and disingenuously) maligning the policy to help keep Sen. Bernie Sanders from winning the Democratic Primary. Further, facing a large GOP majority, Democrats and activists have also been forced to “play defense” just to prevent Donald Trump and the GOP from kicking 24 million Americans off their insurance and doing away with essential benefits like mental health and emergency room visits. These, of course, are important benefits of the Affordable Care Act (ACA), which improved access to health insurance, but leaves about 30 million Americans uninsured. The ACA also can’t control rapidly escalating health costs, a trend which has long been a central problem of our health system.

Indeed, the need for reform beyond the ACA is becoming increasingly clear. A Monmouth poll from February showed that 25 percent of Americans view health care as “the biggest concern facing their family right now.” Health care was, by far, the most cited concern, dwarfing issues like immigration (3 percent) and terrorism (2 percent).

full article:
http://www.truth-out.org…

Single-payer works in other places, why not here?

By Dr. C.V. Allen
The Modesto (Calif.) Bee, April 15, 2017

Every three months there appears in my mailbox a 50-page magazine entitled PNPH Newsletter, the official publication of the Physicians for a National Health Plan.

The magazine is filled with comments and observations of America’s healthcare system. PNHP is strongly committed to the proposition that our system is excessively expensive, ineffective, unfair and should be replaced by a “Medicare for All” program.

Known also as the single-payer system, such plans are common in other industrialized nations. In virtually every instance, they out perform the American system in terms of cost, access and medical outcomes.

Among the many observations in the 2017 Spring edition:

▪ Obamacare, whatever the problems , reduced America’s uninsured population by 41 percent.

▪ In 2017 our healthcare spending is expected to rise by 5.4 percent to $3.5 trillion. That represents 18.3 percent of our gross domestic product, or $10,832 per person. Among other nations the highest GDP expense (Canada and Switzerland) is approximately 11 percent with average cost-per-citizen of about half ours – all while covering all citizens with medical outcomes better than ours.

▪ American employers are shifting healthcare costs to their employee. Deductibles have increased 63 percent from 2011 to 2015. Coinsurance costs for hospital care were 19 percent of charges.

▪ A RAND Corp. study of Oregon’s health system found that overhead costs would be reduced by $600 million by shifting to a single-payer system. A similar RAND study found that with a national single-payer system, the total national costs would be reduced $121 billion (administration costs would fall $556 billion, but medical costs would increase by $435 billion). Coverage would be 98 percent of the entire population.

▪ Longevity is related to economic status. The life expectancy gap between the richest 1 percent and the poorest 1 percent of America’s population is 15 years for men and 12 years for women. Meaning if you’re wealthy, you are likely to live that much longer than your impoverished cousin.

▪ The 8 richest people in the world – six are American – have global wealth equal to the poorest 50 percent of the world’s population.

▪ The five largest commercial health insurance firms made profits of $65 billion from 2011 (when Obamacare began) through 2015. Despite this, the largest firms have cited losses for their withdrawal from the individual insurance market.

▪ The pharmaceutical industry spends nearly $20 million per month lobbying Congress, far more than any other industry. The average profit margin for major drug firms in 2016 was 21.4 percent, far higher than the 7.5 percent margin in all other industries.

▪ Pharmacy firms spend more on administration and marketing than on research. (Novartis 2016 sales $49 billion, profit 36 percent, marketing and administration 29 percent and research 18 percent. For Gilead 11 percent for administration and marketing and only 9 percent for research.)

▪ Sixty percent of Americans say the government should be responsible for ensuring health care coverage for all Americans. The support was 80 percent of Democrats and 32 percent of Republicans. But of Republicans with incomes below $30,000 a year, support rose to 52 percent. All categories show an increasing support for universal healthcare coverage.

Given the failure of President Trump to overturn Obamacare last month, and his promises for “great health care” and a more “simplified” system” that provides “much better numbers,” and “lower deductibles,” and “insurance for everybody,” one might ask if he was thinking of a single-payer system. And if not, why not?

C.V. Allen is a semiretired Modesto physician active in health care reform issues.

http://www.modbee.com…

Medicare for all: Wisely used tax dollars can cover everyone

By Colleen C. Lyons, M.D.
Nevada Appeal (Carson City), April 15, 2017

Dr. Edward Gray’s commentary of April 2 regarding healthcare in America is another frustrating example of a lack of appropriate experience and background. Taking healthcare system advice from a dental subspecialist is certainly of questionable value, given the narrow vista point from which his views are generated.

As a family physician with more than 30 years of experience caring for all sorts of people, including kids and those with mental health concerns, I know one of American’s greatest problems is an ever increasing shortage of primary care doctors, the doctors in the trenches of American medicine. Primary care physicians (family physicians, pediatricians and internists) are the doctors providing the necessary care for nearly 90 percent of what ails you and assisting patients in knowing whether and what specialists to see. Primary care doctors care for their patients over many years and see them back after they’ve been to the specialist and rare subspecialist.

Every other nation in the world has a healthcare system in which primary care doctors represent 50 to 70 percent of the total physicians and surgeons. America’s oft heralded capitalist and free market system has over several decades resulted in a primary care physician workforce of only 30 percent. Numerous studies have shown significant cost savings and improved quality of care when there are higher ratios of primary care physicians per capita, while increased specialists per capita have demonstrated the exact opposite with higher costs and poorer health outcomes.

The 2014 Commonwealth Fund report: “How the Performance of the U.S. Health Care System Compares Internationally” found, yet again, the U.S. ranked last of 11 nations in quality, though we continue to rank No. 1 in cost. The report stated, “U.S. ranks last overall with poor scores on all three indicators of healthy lives — mortality amenable to medical care, infant mortality, and healthy life expectancy at age 60,” and, “U.S. physicians face particular difficulties receiving timely information, coordinating care, and dealing with administrative hassles as other countries have led in the adoption of modern health information systems.” The United Kingdom (Britain/England), maligned by Fred LaSor in his comments in support of Gray, ranked No. 1 in overall quality with the lowest cost of $3,400 versus America’s $8,500 per capita as of 2014.

Having worked as a VA primary care physician for the last five years, I also take issue with the implication of poor quality care provided by the Veterans Health Administration. In truth the VA performs as well as or better than the majority of private sector providers in the United States on a wide variety of measures and certainly at far less expense. The VA has been a leader in initiating numerous safety protocols in hospitals, surgery suites and pharmacy services.

Of course the majority of physicians support malpractice reform and many cite defensive medicine as a significant contributor to healthcare costs in the US. But contrary to popular “wisdom,” studies of this issue don’t support their views regarding the cost of malpractice insurance and/or defensive medicine as a major factor in the overall cost of U.S. medicine.

I concur with Dr. Sean Lehmann’s April 9 rebuttal of Gray and support “improved Medicare for all” as proposed by Physicians for a National Health Plan (PHNP.org). Let us stop, as Lehmann says, “allowing insurance CEOs and shareholders to make all the decisions. Their only motivation being profit, which is a gross conflict of interest.” Trusting an insurance company with your healthcare seems equivalent to trusting a used car salesman; you just don’t. Our forefathers knew capitalism needed the oversight and restraints provided by government to curb excessive greed and abuse of the public good.

The 2010 World Health Report issued by the World Health Organization notes, “Abundant evidence shows that raising funds through required prepayment is the most efficient and equitable base for increasing population coverage. In effect, such mechanisms mean that the rich subsidize the poor, and the healthy subsidize the sick. Experience shows this approach works best when prepayment comes from a large number of people, with subsequent pooling of funds to cover everyone’s health-care costs.”

The Director-General of WHO states, “No one in need of healthcare, whether curative or preventive, should risk financial ruin as a result.” Unfortunately, in America that’s not infrequently the case. The majority of U.S. bankruptcies are due to medical expenses and the majority of those had health insurance at the onset of their illness. I find it necessary to point out the obvious, health insurance is not healthcare — I believe we in America too often discuss medical insurance coverage as though it were actual healthcare.

If we can’t find our way to “improved Medicare for all” and eliminate the insurance middlemen as Canada and France have done at a cost of $4,100 and $4,500 per capita, respectively, then let us at least have nonprofit insurance carriers like Germany and Switzerland have done with a 2014 Commonwealth Fund quality ranking of No. 5 for $4,500 and No. 2 for $5,600, respectively.

Thankfully, a former patient of mine was in Germany as a university student when he was diagnosed with a serious lifelong psychiatric illness. He received far superior care in Germany at no cost to himself than what we attempted to arrange for him upon his return to the U.S. Ultimately, his family realized it would be best to travel with him back to Germany until his symptoms were appropriately controlled with medications.

Interestingly, a recent analysis of U.S. taxpayer expense indicated we already pay more in taxes for healthcare than Switzerland pays in total. Switzerland, the second most expensive healthcare system in the world, provides universal coverage for all its citizens at a cost of approximately $6,200 versus our current $10,000 per capita. We spend tax dollars on the elderly, poor, disabled, veterans and public employees. For the same tax money we could cover everyone, if only we would spend our tax dollars wisely and efficiently on an actual healthcare system instead of the chaos we currently have.

For more information review the following books and/or website:

Regarding how we got in this mess: “SICK: The Untold Story of America’s Health Care Crisis — and the People Who Pay the Price” by Jonathan Cohn.

Regarding VA healthcare: “Best Care Anywhere: Why VA Health Care Would Work Better For Everyone” by Phillip Longman.

Regarding improved Medicare for all, see the Physicians for a National Health Program website at PNHP.org under the “Single Payer” tab. It includes a comparison to the Affordable Care Act (ACA/Obamacare).

Regarding other countries: “The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care,” a New York Times best seller by T. R. Reid.

Dr. Colleen C. Lyons practices family medicine in Carson City. She has more than 30 years of medical practice experience.

http://www.nevadaappeal.com…

CMS final rule benefits insurers, not patients

CMS issues final rule to increase choices and encourage stability in health insurance market for 2018

Centers for Medicare &  Medicaid Services, April 13, 2017

The Centers for Medicare & Medicaid Services (CMS) today issued the final Market Stabilization rule, to help lower premiums and stabilize individual and small group markets and increase choices for Americans.

The final rule makes several policy changes to improve the market and promote stability, including:

* 2018 Annual Open Enrollment Period: The final rule adjusts the annual open enrollment period for 2018 to more closely align with Medicare and the private market. The next open enrollment period will start on November 1, 2017, and run through December 15, 2017, encouraging individuals to enroll in coverage prior to the beginning of the year.

* Reduce Fraud, Waste, and Abuse:  The final rule promotes program integrity by requiring individuals to submit supporting documentation for special enrollment periods and ensures that only those who are eligible are able to enroll. It will encourage individuals to stay enrolled in coverage all year, reducing gaps in coverage and resulting in fewer individual mandate penalties and help to lower premiums.

* Promote Continuous Coverage: The final rule promotes personal responsibility by allowing issuers to require individuals to pay back past due premiums before enrolling into a plan with the same issuer the following year. This is intended to address gaming and encourage individuals to maintain continuous coverage throughout the year, which will have a positive impact on the risk pool.

* Ensure More Choices for Consumers:  For the 2018 plan year and beyond, the final rule allows issuers additional actuarial value flexibility to develop more choices with lower premium options for consumers, and to continue offering existing plans.

* Empower States & Reduce Duplication:  The final rule reduces waste of taxpayer dollars by eliminating duplicative review of network adequacy by the federal government. The rule returns oversight of network adequacy to states that are best positioned to evaluate network adequacy.

“CMS is committed to ensuring access to high quality affordable healthcare for all Americans and these actions are necessary to increase patient choices and to lower premiums,” said CMS Administrator Seema Verma. “While these steps will help stabilize the individual and small group markets, they are not a long-term cure for the problems that the Affordable Care Act has created in our healthcare system.”

https://www.cms.gov…

The final rule (139 pages):
https://s3.amazonaws.com…

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Comment:

By Don McCanne, M.D.

Would people prefer that their health care coverage be adequate and affordable or would they prefer that their insurers thrive in the market even if to the detriment of the beneficiaries? That’s a ridiculous question though the Trump administration has given a ridiculous answer: cater to the private insurers and forget the patients.

The open enrollment period is essentially the only time individuals can enroll in the plans, and they are cutting the eligibility time in half. Further, they are closing the enrollment period two weeks before the end of the year which ensures that procrastinators who wait until the last two weeks before coverage begins are out of luck since they are prohibited from enrolling at all. This will have an obvious detrimental impact to those who tend to put things off or are simply unaware of the early cutoff date. The insurers can target their marketing to healthy populations and get them in quickly and then close the door before the sick people get wind of the short open enrollment period.

Documentation requirements are being increased for special enrollment periods. Since many of those seeking to enroll outside of the open enrollment period do have medical problems that they need to have covered by insurance, the more stringent requirements will allow insurers to refuse coverage for this more expensive population simply because of inevitable difficulties that patients would have in complying with these requirements. Insurers benefit, and people who need care will go without.

People who are unable to pay their premiums because of often unavoidable circumstances, such as loss of employment, will be denied coverage until the delinquent premiums are paid. The insurers get to clear their rolls of poor credit risks while those who do have such problems may have them compounded by being denied insurance coverage.

The rule allows insurers to tinker with the actuarial values of the plans to allow “more choices” (of stripped down plans that offer less protection) and “lower premium options” (for those deficient plans). The insurers get more sales of plans that pay fewer benefits whereas the patients face greater financial hardship should they need health care.

The adequacy of provider networks is a serious problem now, and yet the new rule abandons the federal role in providing oversight of the adequacy off these networks, leaving it to the states, many of which show little regard for such oversight. The insurers profit by ratcheting down the numbers and fees of providers while the patients are left with less certainty that they can access the care they need.

Though we know what increasing choices and lowering premiums really means, our new CMS Administrator, Seema Verma, describes this as “ensuring access to high quality affordable healthcare for all Americans.” It is insurance, not health care, that they are trying to make more affordable, and they certainly are not making actual access to care affordable with the increases in out-of-pocket cost sharing.

We should be particularly concerned with Verma’s statement that these steps “are not a long-term cure for the problems that the Affordable Care Act has created in our healthcare system.” Listening to her answers to questions at her confirmation hearing, she was heavy on the “choice,” “higher quality at lower cost,” and “access” rhetoric while refusing to reveal any real policies that she had in mind. We only know that she, in her own words previously, wants patients to “have more skin in the game.” How can they when so many of them already have been skinned alive?

Northwoods residents gather to support Medicare For All bill

By Evan Verploegh
The Lakeland Times (Minocqua, Wisc.), April 14, 2017

A group of roughly 50 gathered at Torpy Park in Minocqua on April 7 to express their support for H.R. 676, also known as the Expanded and Improved Medicare For All Act.

With periodic support given by honks and thumbs up from passersby, the rally was deemed a success by the Northwood Progressive group, who organized the event. Attendees held signs and peacefully shared their encouragement for the bill to pass through congress.

“No one has given me ‘the finger’ yet,” said a participant of the rally after an hour. “There’s still time, though.”

H.R. 676 establishes the Medicare For All Act, which seeks to provide cost-free health services for medically-necessary care. This includes primary care and prevention, dietary and nutritional therapies, prescription drugs, emergency care, long-term care, mental health services, dental services, and vision care.

Under the bill, health insurers would not be permitted to sell health insurance that would duplicate the benefits of H.R. 676, but would be allowed to sell services deemed unnecessary, such as cosmetic procedures.

The program would be funding by five major sources: (1.) Existing sources of government revenues for health care. (2.) Increasing income tax on the top 5 percent earners in the United States. (3.) Instituting a progressive excise tax on payroll and self-employment income. (4.) Taxation of unearned income, such as interest, dividends and capital gains. (5.) Tax on stock and bond transactions.

The bill also includes language that would provide employment transition benefits for those who would lose their positions with the institution of H.R. 676.

Further, Indian Health Service would be integrated into the program after five years. Congress would also evaluate the current independence of Department of Veterans Affairs health programs.

The single-payer system was introduced to the U.S. House by Rep. John Conyers, Jr. (D-Mich.).

In the wake of administration change, the Northwoods Progressives have been ever-active in conducting similar rallies for causes such as the Women’s March and condemning President Trump’s travel ban for residents of selected Muslim countries.

“I’ve been protesting for over 20 years in the area, and I’ve never seen the kind of political activism that I have in the last few months,” Jerry Woolpy, Northwoods Progressives organizer said. “For awhile, I didn’t know if there was anyone else. The support that has been shown has been inspiring.”

The group will host a March for Science at 10 a.m. on Earth Day, April 22. Beginning at the Calvary Lutheran Church in Minocqua, those in attendance will march to Torpy Park, where a rally will be held.

http://www.lakelandtimes.com…

MedPAC questions effectiveness of MACRA’s MIPS

Evidence-Based Diagnosis and Faith-Based Solutions

By Kip Sullivan JD
The Health Care Blog, April 11, 2017

It’s official: the Medicare Payment Advisory Commission (MedPAC) has at long last decided that MACRA’s MIPS (Merit-based Incentive Payment System) can’t work. MedPAC reached this decision at its January 12 and March 2, 2017 meetings.

Its principle rationale was that measuring “merit” (quality and cost) at the individual physician level, which is what MIPS requires CMS to do, is not possible. As one MedPAC staff person put it at the January meeting, “A redesign of the MIPS program should build off a clear-eyed assessment of the limit of the national Medicare program’s ability to assess clinician performance.”

But the transcripts of the January and March meetings indicate that although MedPAC is now willing to say MIPS is a mess, the commission had not reached a decision about what to do about the mess by the close of the March meeting. The commission’s challenge is obvious. As its chairman Dr. Francis Crosson put it, the issue squarely before the commission now is “whether we just … sit there and watch a dysfunctional thing unravel, or whether we try to make some recommendations which are constructive….”

In previous posts  I have argued that both parts of MACRA – the MIPS program and the Alternative Payment Model (APM) program – can’t work and that MedPAC should recommend that Congress repeal or drastically amend MACRA (the Medicare Access and CHIP Reauthorization Act).

Here is how MedPAC staffer Kate Bloniarz summarized the commission’s indictment of MIPS at the March meeting:

“To reiterate some of the issues with MIPS, first, MIPS uses hundreds of clinician-reported quality measures. Second, two of the other components of MIPS, meaningful use and clinical practice improvement activities, only require attestation by a clinician and haven’t been proven to correspond to high-value care. Third, for any given clinician, there are a relatively small number of Medicare cases, which can contribute to noisy performance. Fourth, under MIPS each clinician is judged based on their own set of measures that they reported, and so the results aren’t comparable across clinicians. In total, we don’t expect that MIPS will be able to identify high- and low-value clinicians and will not be useful for beneficiaries, clinicians, or the program.”

I applaud the commission for being so forthright. I do wonder why it took them so long to reach this conclusion. This conclusion was obvious even before MACRA was enacted, which was two years ago.

http://thehealthcareblog.com…

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Comment:

By Don McCanne, M.D.

The Medicare Payment Advisory Commission (MedPAC) is an independent federal commission that advises Congress on the administration of Medicare. It currently is evaluating the Merit-based Incentive Payment System (MIPS) and the Alternative Payment Model (APM) established by the Medicare Access and CHIP Reauthorization Act (MACRA) – the replacement for the flawed Sustainable Growth Rate (SGR) method of determining Medicare payments.

There was much celebration when SGR was eliminated by MACRA since it would have caused a drastic reduction in Medicare payment rates, but too little attention was given to the substitution in spite of warnings from knowledgeable individuals such as Kip Sullivan. Why is it a problem? As yesterday’s Quote of the Day message indicated, “desktop medicine” has displaced half of face-to-face clinical contact with patients and MIPS is destined to expand the desktop component – a major factor in exacerbating the epidemic of physician burnout. Burned-out physicians glued to desktops cannot be good for patient care.

It took forever to get rid of SGR. It is likely that MedPAC’s recommendations for MIPS and APMs will be all too feeble – recommending bland modifications that will do little to address the fundamental structural problems with the program. As the MedPAC staff member Kate Bloniarz stated, “we don’t expect that MIPS will be able to identify high- and low-value clinicians and will not be useful for beneficiaries, clinicians, or the program.”

The wheel-spinning taking place right now is mostly about replacing volume with value when actual efforts have been quite unproductive. It would be far better to concentrate on reforming our financing system with a well designed single payer national health program – an improved Medicare for all. Once we get the financing right, we can concentrate on much more rational methods of fine tuning that financing.